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Fluid Resus
Fluid Resus
Original Contribution
a r t i c l e i n f o
Article history:
Received 28 November 2016
Received in revised form 18 January 2017
Accepted 20 January 2017
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction 2. Methods
The topic of damage control resuscitation has become increasingly This prospective descriptive 3-year study (2008–2011) evaluated ≥
popular during the last several years [1-4]. This topic involves several 16-year-old patients with blunt trauma and a systolic blood pressure
key concepts that include permissive hypotension (restrictive fluid (SBP) of ≤90 mm Hg at admission. We excluded patients who had re-
resuscitation), which is a strategy that restricts fluid use before any ceived any fluids before the admission, such as patients who had been
bleeding is controlled to avoid excessive blood loss. However, the re- transferred from other hospitals. The standard trauma resuscitation
lated studies have mainly evaluated patients with penetrating injury protocols were used for all other components of care. The patients' he-
and in the pre-hospital setting. Therefore, it is unclear whether this modynamic parameters were recorded after 1 L and 2 L of fluid resusci-
approach provides benefits in cases of blunt trauma or in-hospital tation. Institutional review board (Rinku General Medical Center)
setting. In addition, patients with hypotension should be rapidly stabi- approved the study. Non-response (hemodynamic instability) was de-
lized with a moderate fluid infusion to maintain tissue perfusion. There- fined as sustained hypotension (SBP of ≤ 90 mm Hg) or prolonged
fore, the American College of Surgeon's Advanced Trauma Life Support tachycardia (heart rate [HR] of N 120 bpm) after 1 L and 2 L of fluid re-
training program emphasizes a “balanced” approach to ensure ade- suscitation. All uses of surgery or interventional radiology to control
quate tissue perfusion and minimize the risk of re-bleeding by avoiding hemorrhage were reviewed and reevaluated. We also evaluated the
inadequate or excessive fluid administration [5]. abilities of non-response and SBP after 1 L and 2 L of fluid resuscitation
The Advanced Trauma Life Support and Japan Advanced Trauma to predict the requirement for an immediate intervention using receiver
Evaluation and Care guidelines both recommend an initial rapid infu- operating characteristic curve analysis. All data were presented as
sion of fluid (1− 2 L) as a diagnostic procedure for patients who have mean ± standard deviation.
experienced trauma or hemorrhage [5,6]. However, the appropriate vol-
ume of fluid infusion has not been clearly defined, despite the patient's
responses to the initial fluid resuscitation being critical to selecting an 3. Results
appropriate therapeutic strategy. Therefore, this study aimed to deter-
mine the optimal volume of fluid infusion during the initial resuscita- We enrolled 69 patients, who had an average age of 50.3 ±
tion of patients who had experienced trauma and hypotension. 20.7 years and an average injury severity score of 29.9 ± 13.9. Thirty-
nine patients required an intervention, and 30 patients did not require
an intervention for control hemorrhage. The sites of hemorrhage for
the cases that required an intervention were pleural hemorrhage
(n = 3), peritoneal hemorrhage (n = 12), retroperitoneal hemorrhage
⁎ Corresponding author at: Senshu Trauma and Critical Care Medical Center, Rinku (n = 19), and other sites (n = 6). The overall mortality rate was 23.2%.
General Medical Center, 2-23 Rinku Orai-Kita, Izumisano, Osaka 598-8577, Japan.
E-mail addresses: y-mizushima@rgmc.izumisano.osaka.jp (Y. Mizushima),
Thirteen patients in the IV groups died because of hemorrhagic shock.
s-nakao@rgmc.izumisano.osaka.jp (S. Nakao), k-idoguchi@rgmc.izumisano.osaka.jp The sites of hemorrhage in these patients were the pleura (n = 3), peri-
(K. Idoguchi), t-matsuoka@rgmc.izumisano.osaka.jp (T. Matsuoka). toneum (n = 4), and retroperitoneum (n = 6). All sources of bleeding
http://dx.doi.org/10.1016/j.ajem.2017.01.038
0735-6757/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Y. Mizushima et al. / American Journal of Emergency Medicine 35 (2017) 842–845 843
Table 1
Characteristics of the study patients.
IV groups No IV groups p
No. of patients 40 29
Age (y) 47.1 ± 21.3 54.6 ± 19.4 0.52
Initial SBP (mmHg) 69.1 ± 15.0 73.1 ± 14.6 0.93
ISS 34.3 ± 14.1 24.4 ± 11.8 0.53
RTS 5.23 ± 1.68 5.32 ± 1.91 0.27
TRISS 0.61 ± 0.35 0.66 ± 0.37 0.28
Mortality 13 (32.5%) 3 (10.3%) b 0.01
IV, intervention; SBP, systolic blood pressure; ISS, Injury Severity Score; RTS, Revised Trau-
ma Score.
Fig. 3. Systolic blood pressure (SBP) and heart rate (HR) after 2-L fluid resuscitation. The
Fig. 1. Systolic blood pressure (SBP) and heart rate (HR) at admission. Closed circles: average fluid rate was 61 mL/min. Non-response after 2-L fluid resuscitation had a
patients who required immediate interventions for bleeding. Open circles: patients who predictive value of 80.0% for intervention and a negative predicting value of 52.6% for no
required no interventions. intervention.
844 Y. Mizushima et al. / American Journal of Emergency Medicine 35 (2017) 842–845
Fig. 4. Receiver operating characteristics (ROC) curve for systolic blood pressure (SBP) after 1-L and 2-L fluid resuscitation to predict intervention. The area under the ROC curve was 0.72
after 1-L fluid resuscitation, and the area under the ROC curve was 0.68 after 2-L fluid resuscitation.
potentially displace established clots and cause hemorrhage recurrence. Our results indicate that non-response after 1 L of fluid resuscitation
Thus, there is a strong argument that excessive fluid administration may provided a better ability to predict the need for intervention, compared
aggravate any organ failure, and that additional fluid should not be ad- to non-response after 2 L of fluid resuscitation. Furthermore, the receiv-
ministered except to correct hypotension. Nevertheless, most studies of er operating characteristic curve for SBP provided the highest value
restricted fluid resuscitation evaluated cases with penetrating injuries, after 1 L of fluid resuscitation (vs. at admission or after 2 L of fluid resus-
and it is easy to identify the site(s) of bleeding in these cases [4,8]. citation). Therefore, it might be more appropriate to evaluate patient re-
Thus, it may be more difficult to identify cases of blunt trauma that re- sponse after 1 L of fluid administration (vs. after 2 L) to assess the need
quire surgical interventions based on vital signs at admission, and the for an intervention to stop bleeding
patient's response to fluid resuscitation is critical to determining the The findings of this study are limited by the single-center design and
subsequent therapy. Moreover, in the present study, 30 of the 69 pa- small sample size. Thus, large multicenter studies are needed to confirm
tients (43%) who had experienced trauma and hypotension did not re- these preliminary results, and to evaluate the utility of 1-L fluid resusci-
quire any interventions for bleeding. tation. Nevertheless, fluid resuscitation at a moderate rate and volume
Few reports have described the initial fluid resuscitation volume and may help provide better identification of patients who require immedi-
rate, although one study used propensity analysis to control for group ate interventions.
differences and concluded that N500 mL of fluid corrected hypotension
and improved the mortality rate among patients with pre-hospital hy- 5. Conclusions
potension [3]. Thus, most studies of restricted fluid strategies have
been performed in the pre-hospital setting. Furthermore, Schreiber et Our findings show that increasing the fluid administration vol-
al. performed a randomized study of controlled resuscitation (mean ume did not provide a better ability to predict the need for interven-
crystalloid volume: 1 L) and standard resuscitation (mean crystalloid tion. Moderate fluid resuscitation should be considered to determine
volume: 2 L), which revealed that the controlled resuscitation strategy patients' response to the initial fluid resuscitation in trauma patients.
was feasible and safe among hypotensive trauma patients in the pre-
hospital and in-hospital settings [7]. These findings indicate that a mod- Acknowledgements
erate resuscitation volume may be appropriate for these patients in the
pre-hospital and in-hospital settings. We would like to thank Editage (www.editage.jp) for English lan-
Ley et al. have also demonstrated that ≥1.5 L of emergency crystal- guage editing.
loid fluid resuscitation was an independent risk factor for mortality
among elderly and non-elderly patients who had experienced trauma References
[9], which indicates that an emergency intervention or a rapid intensive
care unit admission should be considered if ≥1.5 L of fluid is required to [1] Duchesne JC, McSwain Jr NE, Cotton BA, Hunt JP, Dellavolpe J, Lafaro K, et al. Damage
control resuscitation: the new face of damage control. J Trauma 2010;69:976–90.
maintain adequate blood pressure [9]. Moreover, Hagiwara et al. have [2] Duke MD, Guidry C, Guice J, Stuke L, Marr AB, Hunt JP, et al. Restrictive fluid resus-
reported that a shock index of ≥1 after 1 L of resuscitation was assigned citation in combination with damage control resuscitation: time for adaptation. J
to patients who required a blood transfusion or intervention for active Trauma Acute Care Surg 2012;73:674–8.
[3] Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, et al. Prehospital in-
bleeding [10]. Thus, low-volume fluid resuscitation appears to have travenous fluid administration is associated with higher mortality in trauma pa-
competing benefits (identification of the patient's response after blunt tients: a National Trauma Data Bank analysis. Ann Surg 2011;253:371–7.
trauma) and risks (reduced tissue perfusion among patients with [4] Bickell WH, Wall Jr MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate
versus delayed fluid resuscitation for hypotensive patients with penetrating torso
shock who respond to fluid). Therefore, it appears that a moderate
injuries. N Engl J Med 1994;331:1105–9.
fluid infusion rate and volume should be considered to evaluate the [5] American College of Surgeons Committee on Trauma. Advanced trauma life support:
patient's response to fluid resuscitation. Student manual. 9th ed. Chicago, IL: American College of Surgeons; 2012.
[6] Developing committee on the course of trauma care training of the Japan Associa-
Our previous study demonstrated that increasing the fluid adminis-
tion for the Surgery of Trauma. Guidelines for initial trauma care. Japan Advanced
tration rate (to N 60 mL/min) did not produce hemodynamic stability, Trauma Evaluation and Care. 4th ed. Tokyo: Herusu Shuppan Company; 2012 [in
and that more aggressive fluid resuscitation rates may result in exces- Japanese].
sive fluid resuscitation [11]. Therefore, the present study used a moder- [7] Schreiber MA, Meier EN, Tisherman SA, Kerby JD, Newgard CD, Brasel K, et al. A con-
trolled resuscitation strategy is feasible and safe in hypotensive trauma patients: re-
ate rate that is approximately equal to the rate that is provided by a sults of a prospective randomized pilot trial. J Trauma Acute Care Surg 2015;78:
fully-open 16-G peripheral intravenous catheter. 687–97.
Y. Mizushima et al. / American Journal of Emergency Medicine 35 (2017) 842–845 845
[8] Wang CH, Hsieh WH, Chou HC, Huang YS, Shen JH, Yeo YH, et al. Liberal versus re- [10] Hagiwara A, Kimura A, Kato H, Mizushima Y, Matsuoka T, Takeda M, et al. Hemody-
stricted fluid resuscitation strategies in trauma patients: a systematic review and namic reactions in patients with hemorrhagic shock from blunt trauma after initial
meta-analysis of randomized controlled trials and observational studies*. Crit Care fluid therapy. J Trauma 2010;69:1161–8.
Med 2014;42:954–61. [11] Mizushima Y, Tohira H, Mizobata Y, Matsuoka T, Yokota J. Fluid resuscitation of trau-
[9] Ley EJ, Clond MA, Srour MK, Barnajian M, Mirocha J, Margulies DR, et al. Emergency ma patients: how fast is the optimal rate? Am J Emerg Med 2005;23:833–7.
department crystalloid resuscitation of 1.5 L or more is associated with increased
mortality in elderly and nonelderly trauma patients. J Trauma 2011;70:398–400.